血小板功能检测或基因检测指导的双联抗血小板药物降阶治疗对行经皮冠状动脉介入治疗的急性冠脉综合征患者预后影响的Meta分析

Effect of Platelet Function Testing or Gene Testing Guided De-escalation of Dual Antiplatelet Therapy on the Prognosis of Patients with Acute Coronary Syndrome Undergoing PCI:a Meta-analysis

目的 系统评价血小板功能检测或基因检测指导的双联抗血小板药物降阶治疗对行经皮冠状动脉介入治疗(PCI)的急性冠脉综合征(ACS)患者预后的影响。方法 计算机检索Cochrane Library、PubMed、Embase、Web of Science及相关学会年会的摘要和报告中PCI后采取血小板功能检测或基因检测指导的双联抗血小板药物降阶治疗与标准双联抗血小板治疗的ACS患者的随机对照试验(RCT)和队列研究,其中降阶治疗组患者采用血小板功能检测或基因检测指导的双联抗血小板药物降阶治疗,标准治疗组患者接受标准双联抗血小板药物治疗。采用Stata 15.0软件进行Meta分析,比较两组患者PCI后12个月主要终点事件(主要不良心脑血管事件)、主要安全终点事件(出血、显著临床出血事件)及次要终点事件(全因死亡、心源性死亡、心肌梗死、卒中、支架内血栓形成、再次血运重建)发生率。结果 最终获得文献6篇,包括6 711例患者,其中RCT 3篇,均有一定偏倚风险;队列研究3篇,均有中等偏倚风险。Meta分析结果显示,两组患者主要不良心脑血管事件发生率[RR=0.72,95%CI(0.51,1.02)]、出血发生率[RR=0.74,95%CI(0.51,1.07)]、全因死亡率[RR=1.08,95%CI(0.67,1.75)]、心源性死亡率[RR=0.72,95%CI(0.38,1.37)]、心肌梗死发生率[RR=0.82,95%CI(0.57,1.16)]、卒中发生率[RR=0.61,95%CI(0.30,1.24)]、支架内血栓形成发生率[RR=0.69,95%CI(0.21,2.23)]、再次血运重建发生率[RR=1.14,95%CI(0.78,1.66)]比较,差异无统计学意义(P>0.05)。降阶治疗组显著临床出血事件发生率低于标准治疗组,差异有统计学意义[RR=0.75,95%CI(0.64,0.89),P<0.05]。结论 在接受PCI的ACS患者中,通过血小板功能检测或基因检测指导双联抗血小板药物降阶治疗可降低患者显著临床出血事件发生风险,同时不增加缺血事件。

Objective To systematically evaluate the effect of platelet function testing or gene testing guided deescalation of dual antiplatelet therapy on the prognosis of patients with acute coronary syndrome(ACS)undergoing percutaneous coronary intervention(PCI).Methods Randomized controlled trial(RCT)and cohort study about patients with ACS treated with de-escalation of dual antiplatelet therapy guided by platelet function testing or gene testing and standard dual antiplatelet therapy after PCI in the Cochrane Library,PubMed,Embase,Web of Science,abstracts and reports of the annual meetings were retrieved by computer.The patients in the de-escalation therapy group were treated with de-escalation of dual antiplatelet therapy guided by platelet function testing or gene testing,and the patients in the standard therapy group were treated with standard dual antiplatelet therapy.Meta-analysis was performed with Stata 15.0 software to compare the incidence of primary endpoint events(major adverse cardiovascular and cerebrovascular events),primary safety endpoint events(bleeding,significant clinical bleeding events)and secondary endpoint events(all-cause death,cardiac death,myocardial infarction,stroke,stent thrombosis and revascularization)at 12 months after PCI between the two groups.Results Six literature were finally obtained,including 6711 patients;there were 3 RCT,with a certain risk of bias;3 cohort studies,with moderate risk of bias.The results of meta-analysis showed that there was no significant difference in the incidence of major adverse cardiovascular and cerebrovascular events[RR=0.72,95%CI(0.51,1.02)],incidence of bleeding[RR=0.74,95%CI(0.51,1.07)],all-cause mortality[RR=1.08,95%CI(0.67,1.75)],cardiogenic mortality[RR=0.72,95%CI(0.38,1.37)],incidence of myocardial infarction[RR=0.82,95%CI(0.57,1.16)],incidence of stroke[RR=0.61,95%CI(0.30,1.24)],incidence of stent thrombosis[RR=0.69,95%CI(0.21,2.23)],incidence of revascularization[RR=1.14,95%CI(0.78,1.66)](P>0.05).The incidence of significant clinical bleeding events in the de-escalation therapy group was significantly lower than that in the standard therapy group[RR=0.75,95%CI(0.64,0.89),P<0.05].Conclusion In ACS patients undergoing PCI,de-escalation of dual antiplatelet therapy guided by platelet function testing or gene testing can reduce the risk of significant clinical bleeding events without increasing ischemic events.